By Joseph Harris, Assistant Professor of Sociology, Boston University. Originally published at The Conversation

The open enrollment period for the Affordable Care Act (ACA) draws to a close on Dec. 15. Yet, recent assaults on the ACA by the Trump administration stand in marked contrast to efforts to expand access to health care and medicine in the rest of the world. In fact, on Dec. 12, the world observed Universal Coverage Day, a day celebrated by the United Nations to commemorate passage of a momentous, unanimous U.N. General Assembly resolution in support of universal health coverage in 2012.

While the U.N. measure was nonbinding and did not commit U.N. member states to adopt universal health care, many global health experts viewed it as an achievement of extraordinary symbolic importance, as it drew attention to the importance of providing access to quality health care services, medicines and financial protection for all.

Co-sponsored by 90 member states, the declaration shined a light on the profound effect that expansion of health care coverage has had on the lives of ordinary people in parts of the world with far fewer resources than the U.S., including Thailand, Mexico and Ghana. Can the U.S. learn anything from these countries’ efforts?

US and Thailand: A Study in Contrasts

I came to understand these changes as I researched and wrote my book, “Achieving Access: Professional Movements and the Politics of Health Universalism.” The book offers a comparative and historical take on the politics of universal health care and AIDS treatment, featuring Thailand as the primary case. For me, Thailand’s remarkable achievements also put into perspective some of the work we still have to do here in the United States with respect to health reform.

Before the reform, Thailand had four different state health insurance schemes, which collectively covered about 70 percent of the population. The reform in 2002 consolidated two of those programs and extended coverage to everyone who did not already receive coverage through the country’s health insurance programs for civil servants and formal sector workers.

Thailand’s universal coverage policy contributed to rising life expectancy, decreased mortality among infants and children, and a leveling of the historical health disparities between rich and poor regions of the country. The number of people being impoverished by health care payments also declined dramatically, particularly among the poor.

However, Thailand’s reform had other important consequences that aimed to make the reform sustainable as well. Sensible financing and gatekeeping arrangements – that tied patients to a medical home near where they lived and provided fixed annual payments for physicians to cover outpatient care – were instituted to curb the kind of cost escalationthat has historically been a hallmark of the United States (though it has slowed lately). The reform also improved the quality of care for patients in remote areas by mandating that qualified providers in community hospitals collaborate more extensively with rural health centers.

Moreover, effective repeal of the Affordable Care Act’s individual mandate through a provision in the 2017 Tax Reconciliation Act that reduces the penalty for not having insurance to zero in 2019 will have the effect of reducing the number of insured. This will have an effect on health insurance markets, likely reducing the number of younger and healthier people that help give balance to health insurance risk pools and that help keep overall costs down. And without the financial protection afforded by health insurance, those who are uninsured may face rising rates of medical bankruptcy, to say nothing for the loss of access to sorely needed medical care.

Reformers also drew on other innovative policy instruments to keep costs down, including the Government Pharmaceutical Organization that produces generic medication for the universal coverage program and the use of compulsory licenses, which allow governments to produce or import generic versions of patented medication under WTO law.

The Affordable Care Act similarly sought to improve access, while curbing costs. Some of the most important mechanisms to curb costs fell victim to the legislative process however. Most notably, lobbyists succeeded in killing the “public option,” a government (as opposed to private) health insurer with much lower administrative costs that aimed to bring costs down among private health insurers through competition with them….

What the contrast makes clear, however, is that reforms done properly can expand access while at the same time instituting measures that help to contain costs. The U.S., in my view, should pursue similarly creative and constructive reforms that seek to do both.

What does that look like in the United States? To me, that means preserving the ACA’s individual mandate and protections related to pre-existing conditions; creating (or expanding) a public insurer like Medicare to compete alongside private insurers and keep costs down; addressing the lack of price transparency in our nation’s hospitals; and actively negotiating with pharmaceutical companies and hospitals to bring costs of drugs and health care down for millions.

Done sensibly, developing nations like Thailand are proving that they do not have to join the ranks of the world’s wealthiest nations for their citizens to enjoy access to health care and medicine. Using evidence-based decision-making, even expensive benefits, like dialysis, heart surgery and chemotherapy, need not remain out of reach. Policymakers in all countries can institute reforms using tools that promote cost savings at the same time they improve access and equity.

While efforts to implement universal coverage are not without challenges, these results suggest that leaders in Congress would do well to learn from countries like Thailand as they chart a fiscally responsible path forward on health care.

Post navigation

48 comments

From the perspective of a non Thai but living in Thailand this is an excellent article. The system has done wonders for the lower income portion of society. Yet it has retained a competitive private sector that competes on quality and price. As a foreigner here I have a choice of stunning first class hospitals with medical professionals having degrees from the best medical schools in the world. Quality of care is the best I’ve encountered anywhere in the world. Prices are very reasonable and because many of the foreigners here pay out of pocket, the hospitals treat us as customers…and compete for our business. Though I’m not a medical professional, from the customer’s perspective this two tier system seems to accomplish both affordable Care for the lower income Thais while retaining a market based portion for well off Thais, expats and medical tourists.

Health care in Thailand for everyone is pretty good. What do you expect? People with more money can always get top-tier care, but when people who have the least are taken decent care of, how can you argue with that?

The Thai government established a system of rural health care centers staffed by paramedics. Medicine was subsidized, and costs were/are very low (in fact I think the /anamai/ are now part of the universal coverage: 1 illness = ฿30 (฿30 is about equal to $1). That means a Thai citizen pays just ฿30 for the full course of treatment, no matter how complex it becomes or how much hospitalization is required. This rural system was established by King Chulalongkorn, who died in 1910. The current system was created by Prime Minister Thaksin Shiawatra, who was overthrown in 2006. The junta wanted to abolish his system but quickly came to realize that if they did the entire North and Northeast would revolt, so they made some small improvements instead.

I think a more directly applicable example is Taiwan. In the 1990’s Taiwan explicitly adopted the Medicare model, they just made it universal. While not perfect, the Taiwan system is very cost effective (I think around 7% GNP, maybe 40% of US expenditure). Taiwan is in effect a nice laboratory for seeing what works and what doesn’t work in a Medicare for All type single payer system.

An issue in Thailand is that it has a huge medical tourism industry – very large numbers of Chinese, Vietnamese, etc., travel there to the hospitals. This effectively subsidises a very high quality of care in certain medical fields, although this can have a distorting effect, not least that doctors can earn a lot more in a private clinic than the public system.

If you read the Wikipedia article for the late, great Uwe Reinhardt, there’s a short dedicated section on his key contribution to the Taiwanese system. He taught at Princeton for an additional 28 years after the Taiwanese reform, and no one from our vaunted, essential elites bothered to call on his expertise in a significant way.

Know enough Taiwanese expats in America to say that they will never stop paying their $30 monthly fee for their national plan. And every non-emergency medical expenditure is compared to round trip air plus any cost of service in Taipei. For example elective Lasik service at the top clinic in the country cost one of them $1800 for both eyes. Best I could find was $2500 each and they couldn’t even coach me on how to game a FSA to do one eye Dec 31 and the other Jan 2 to at least avoid taxes. Needless to say, still wearing glasses.

The system in Thailand seems to be publicly financed insurance, not a public plan ” to compete alongside private insurers” as recommended above. As far as I’m aware, no country which has achieved universal healthcare has done so with private, for-profit insurance as the basis for the standard universal benefits.

Japan is classified by PNHP as having the Bismarck model rather than the Canadian style national health insurance model, but I think it is closer to the Canadian system, especially Japan’s “people’s health insurance” system for those who are not employees of large companies. I’m not as familiar with the “social health insurance” program for large-company employees, which is administered by associations for employees of each company, but the overall system is public and has common requirements. PNHP’s source may be TR Reid’s book which classified Japan as having the Bismarck model.

Yes, the PNHP summary is based on T.R. Reid’s book. In the book he says that Japan chose the German system as the model. He also gives some detail regarding differences, including how the insurance plans are organized, but in both cases the insurance is not-for-profit.

great link.
what a clear division for the purpose of discussion.
Now it would be nice if the US had a collective sanity. We could create a national healthcare model that was paid for by the function of our ability to create our own money. Given to the congress by the constitution.;the original intent.
Not to the fed, to be borrowed by the government(with interest) after being given to the financial services industry elite to manipulate wall street, as the 16th amendment intends, and we have practiced for the last 100 years… and supports the for profit model that is at odds with the lives and health of everyone in this country., while it wastes our money…. and earns us the right to be called “stupid” with our money.

There are many, many privately owned hospitals in Thailand. They are allowed to charge additional fees on top of the government care, so are much less crowded than the government hospitals. Thais who can afford it go to them. I use one, and the normal fee for a doctor’s consultation is about $10. Medicine from the hospital pharmacy is more expensive than from the many, many pharmacies outside. Pharmacists, by the way, are held to a very high standard. It’s complicated, but in addition to the universal health care plan there is a “social security” plan for employees of corporations that pays for people to go to the publicly owned hospitals, and private insurance is available as well. Also, most doctors operate private “clinics” which mostly make their profit from the markup on medicines.

As has been noted on NC many times before: “access” and “coverage” do not equal medical care. PlutoniumKun is absolutely right: we want the Taiwanese model, NOT the Thai model. This interview from 2009 explains:http://pnhp.org/?s=taiwan

If y’all recall, 2009 was when Congress took single-payer off the table, and we got Obamacare.

One of the Thai concerns during the TPP negotiations was that pharmaceutical companies wanted the Thai government to stop producing generics. The Thais thought they were going to get steamrolled in the TPP.

I have always wondered about the business ethics of private companies profiting from war and suffering by manufacturing weapons and drugs. I would prefer these be developed and manufactured by government facilities.

Yah, Uber and Amazon spring immediately to mind, and of course HCA under our new Senator, Rick “Skeletor” Scott, which ripped the public treasury off for what, $9 billion, by various scams (and paid cents on the dollar in fines and NO sanctions at all for Sick Rott himself.)

I worked for 15 years in state and federal government regulatory agencies, where even in the ‘70s and ‘80s you had to fight the frictions and caution inherent in all bureaucracies, and then the intentional adversity of the Reaganauts, to move even lay-down blatant cases of intentional violation of public protection laws through to the point of a case finally being filed.

And then you got to watch as cautious or corrupt government lawyers (US Attorneys and Main Justice) whittled down the cases and found ways to write the hidden law of settlement policy guidance documents” and such to “make legal” their cutting of sweetheart settlement deals that gave a “win” and a nice photocopied, and often tax-decucitible-cost-of-doing-business, “settlement check” to hang on their scalp-belt wall. Those agencies and the government lawyers have only gotten either corrupt and captured, or weaker and more hamstrung, and seen their mandates and enforcement tools and courage all shrunk and blunted.

So your argument, while “ideally” could be “the way it ought to work”? I’d have to say, far as I am concerned, the notion contains significant amounts of wishful thinking.

Some form of Medicare for all seems to be what most Americans desire. It wouldn’t be a perfect system but one substantially better than what we have and capable of improvement as we learn our way along through experience. What other countries have done to provide more universal health care should obviously be considered as potential models to draw upon. But on an even more fundamental level, perhaps we should be looking not only at alternative systems of providing health care but also at alternative understandings of disease and modes of treatment:

I have been researching health care and health care benefits as part of a employee committee for the past several months rather intensively. My first reaction to this article, after that research experience is, “this guy thinks of “healthcare” entirely in the abstract”. I suspect his employer provides him a cadillac plan with a very high income, so he sees “insurance” as a one stop shop to all levels of care. Just a few legislative tweaks here and there, and things will proceed swimmingly.

Back in the real world, we have discovered that the system in the US is rotten to the core. No transparency in pricing or product, no access to quality outcome measures, no preventative measures as a matter of health policy, (sick people are profit centers afterall). Unstable networks, lack of access to overpriced care due to gate keeping such as large upfront payments before costly procedures. Skyrocketing dedictibles, premiums, and out of pocket costs. The list goes on and on. Frankly, nothing short of a popular socialist revolution can excise the rot in this system …

Obama went down on his knees and opened wide to the massive breadth and girth of the for-profit insurance industry. Hard to imagine enflaccidating that power base anytime soon. So maybe the example is The Netherlands, who were faced with similar dynamics. They kept the for-profit insurers relatively intact, but forced them to provide a basic package of services at a fixed cost, universally available, and compete above that with value-added services. (OMG there’s that word: competition)

Maybe some Nederlandse mannen en vrouwen can chime in with the local details?

likely reducing the number of younger and healthier people that help give balance to health insurance risk pools and that help keep overall costs down.

I understand that this is the Holy Grail for all those who want someone else to pay for medical care. But that is also the group that is being screwed by every single other effort to get someone else to pay. And it is repugnant that in virtually all proposals to ‘reform’ healthcare – there is absolutely nothing in any of them to actually fix the damn problems that lead to that need to force someone else to pay.

The only way to reduce costs in any medical care system is to reduce utilization – which means serious gatekeeping and a lot of squawking from those who overutilize simply because ‘insurance is paying for it’. If the squawking doesn’t happen (esp in US), then there isn’t near enough gatekeeping.

The only way to fund future medical spending – ie ‘lifetime medical planning’ where the young/healthy will prefund their own proj spending when they are old/sick – is to break out of the one-year cash-outlay mindset. Which also has the benefit of making preventive care and GP access more worthwhile.

While Thailand is a nice model – it’s kind of irrelevant to the US which is choking on a SPENDING problem which is actually far worse than our access problem

This is simply counterfactual. First, all insurance has the people who don’t use it/wind up needing it subsidizing those who do. And the idea that young people don’t need it is fallacious. Ever check out what pregnancy costs? And you are seriously telling me young people don’t get in car crashes, get cancer, have smoke inhalation injuries due to proximity to fires, or get infections? The bad winter flu of 3 years ago had the highest fatality rate in 30-40 years olds, and sent them to the emergency room at the highest rates too. The median age of those who got seriously ill from the latest E-coli outbreak, the one that led to the romaine recall, was 26 (https://www.cdc.gov/ecoli/2018/o157h7-11-18/index.html)

Your assertions are by the experience of other countries who have lower costs and better health care outcomes. The rationing argument is a right wing Big Lie. In Canada, there is some queuing for surgeries where delay does not impact efficacy, but that’s as bad as it gets.

As a young, mostly healthy person who has nonetheless been nearly bankrupted by sudden medical expenses, I can safely say (family blog) you and everyone like you who tries to claim “people like me” are going to be somehow victimized by universal, single-payer healthcare. I say this for two reasons:

1. EVERYONE, no matter how young, gets sick sometimes. Occasionally, this can be something quite serious. And in this country, one serious illness can mean impoverishment, losing one’s job, or having your savings wiped out (if you’re fortunate enough to have savings).

2. It is unethical in the extreme to say, “I’m healthy, I don’t need to go to the doctor today, why should I have to pay for someone else’s care?” (Not to mention that in a federally funded system, you wouldn’t be “paying” for anything because federal taxes don’t fund federal spending) That’s literally saying you don’t give a (family blog) if someone else dies for lack of healthcare, because they should’ve been saving up to pay for getting sick. I don’t drive, but when my state Gov’t taxes me to pay for roads, I don’t whine that I shouldn’t have to pay for those.

1 The Lord sent Nathan to David. When he came to him, he said, “There were two men in a certain town, one rich and the other poor. 2 The rich man had a very large number of sheep and cattle, 3but the poor man had nothing except one little ewe lamb he had bought. He raised it, and it grew up with him and his children. It shared his food, drank from his cup and even slept in his arms. It was like a daughter to him.

4 “Now a traveler came to the rich man, but the rich man refrained from taking one of his own sheep or cattle to prepare a meal for the traveler who had come to him. Instead, he took the ewe lamb that belonged to the poor man and prepared it for the one who had come to him.”

5 David burned with anger against the man and said to Nathan, “As surely as the Lord lives, the man who did this must die! 6 He must pay for that lamb four times over, because he did such a thing and had no pity.”

Reduce Utilization? I’d say utilize more if anything – with emphasis in preventive care. Nationalize the whole system – something like Canada, perhaps… Does not other countries experience bring us to the conclusion it will also save the USA more and with better outcomes… side effect – happier people – more cohesive people.
The current system needs an overhaul – we’ve gone down the private road – we’ve gone down the public – (Medicare/Medicaid) road – Time to expand the latter.

I totally agree that preventive is the best long-term solution. But let’s not pretend that the federal govt per se is actually the solution to that.

Medicare has been around for decades. For just as long, we have known that boomers will get older and eventually retire – where the govt health plan is the single-payer for that demographic. Which also needs ‘preventive’ – and in that case that means geriatricians serving a much larger role – as both GP’s for the elderly and gatekeepers to the expensive specialist stuff.

And golly – with 50 years of TOTAL predictability of that future need – we have fewer geriatricians than Denmark and the number is DROPPING. And from those who are advocating Medicare-for-all – crickets on that. They can’t fix an existing issue of Medicare itself – and aren’t interested either. How is that evidence they can assume MORE responsibility?

I am german- canadian, and absolutly prefer the canadian system. That does not mean, that there are not a lot of problems in the canadian system, but nothing would be fixed by privatizing. Improvment would be possible by stopping the ever increasing administrative apperatus. I think basic free health care for everybody and all children through the taxes is a really good idea.
Meanwhile Germany has the strange “ public” and “ private “ health insurance system, were everybody rich more or less gets pushed into the private insurance systems, which is fine when you are young and sucessfull, but ones you are older and have not a lot of money you can not switch back. ( My father is 83 and pays about 700 euro each month, that is almost half his pension into his the private health insurance)
Since there are many healthinsurances, they create so much more bullshit jobs and administrative loads, the “ public insurances” for lower incomes are private companies as well and one has to be in there, even if some people can absulutly not afford it.
And the people who make all decisions about this ( goverment, Parliament etc., state servants) do not have to pay any healthinsurance at all – so the whole system sucks…

A quick look through the costs per country of healthcare shows that the ‘Bismarkian’ system tends to be more expensive than the ‘direct provision’ or ‘single payer’ models. It’s not hard to see why – its involves a lot more administration and bureaucracy. As an example, the Netherlands system (similar to the German one) is often held to be the best in the world, but its internal workings are so labyrinthine few outside the system seem to understand exactly how it works.

Having lived in Canada for 35 years before moving to portugal and a German by birth with living 30 years there, I have experience in three health care systems now.

The Canadian system of course has problems, but functions well overall and is very affordable for an individual and family and is inclusive for everyone. Excluded services include dental care, ophthalmological care and physiotherapy.

The German system as you point out can be costly if you are self employed. As an employee there are few problems.

Portugal’s system is all inclusive and the contributions are based on income and paid by the employer. as part of the salary. The seguranca social however is a package insurance that includes healthcare, unemployment and maternity leave. As a self employed person below a certain income – about 6000€/ year you pay a monthly contribution of 20€. Beyond that you pay a higher rate, the average about 120€/month. As a pensioner you are exempt from any fees.

There are private clinics that charge upwards of 75€ for the first visit to then 35€ for each consecutive visit. The hospitals are government run, and even the referrals from private clinics (whose Doctors are also often part of the public funded system as specialists needing to use public funded surgery facilities or labs) have to move into line with everyone referred from the centros de saude, the public clinics.
My wife had two total knee replacements here on an Island in the middle of the Atlantic, and the quality of service was no different than the two I had in Canada but with much better after surgery care. Like the nurses if you live outside the city coming to your house for change of bandages or the after care to assess on a yearly basis the outcome of the surgery after the first year during which you see the doctor every four month.
Physiotherapy can be private at about 30€/hour or in the hospital – which is excellent and every three days (or more often if you choose and space is available) – at 4 € per session.
Excluded are like in Canada dental, ophthalmological care.

On my teeth: I can’t really compete with the commenters here because my problems are simple. I wrote:

I had four wisdom teeth pulled in Thailand, and that more than paid for the plane fare. Very competent, and above all no pain and amazingly very little stress. They seemed to be accustomed to patients whose entire bodies would go rigid in the chair because of their experience with the American dental system.

When I went to get my teeth examined at the clinic in the States, the whole experience was so horrible I couldn’t relax at all, so they recommended general anesthesia. “Make sure to arrange for somebody to drive you home.” No thanks. No thanks to any of it.

The Thai nurses kept saying “no pain, no pain” and they were right! The American system seems designed to create pain (and then charge for drugging it).

A consequence of ObamaCare’s needlessly complex structure, which seems to have been designed to present as many attack surfaces as possible to opponents.

In the last big ACA case (too lazy to find the link) the Court opined that although the ACA was unconstitutional under the Commerce clause, it was constitutional as an exercise of Congress’s taxing power. Then the Republicans zeroed out the ACA’s “shared responsibility payment,” which knocked the props out from under the taxing argument — at least according to this judge. I skimmed the opinion, and I think there’s a prima facie case for the Texas judge being right.

As I said, it all goes back to the ACA”s program design. The concept is that the government, the insurance companies, and the individual each have “shared responsibilities,” which are carried out through the market. Hence the rationalization for the “shared responsibility” payment at tax time, for those who choose not to buy a defective product insurance.

The law, which I spent some 36 years “practicing,” has developed into a labyrinth of rules with exceptions, and exceptions to exceptions, and exceptions to exceptions to exceptions, etc., in an ever-escalating regress into utter casuistry. No doubt there’s a prima facie case for the decision of the Texas judge, as well a prima facie case for the making of the opposite decision, as well as a prima facie case for coming down someplace between the poles of affirming or striking down the act in its entirety. The difference between having no rules whatsoever and having a plethora of rules intermeshed in a bewildering and expanding complex of ever-more-subtle exceptions, is IMHO a rather thin distinction. Both boil down to a government of men/women rather than a government of law.